Common CQL Artifacts for FHIR (US-Based)
1.0.0 - Informative 1 United States of America flag

This page is part of the Common CQL Assets for FHIR (US-Based) (v1.0.0: Informative 1 - Informative) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Questionnaire: Example Medical Benefit Outpatient Drug Authorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire Version: 1.0.0
Standards status: Informative Computable Name: MBODAQuestionnaire

Copyright/Legal: This content is is informed by the following source, used with permission: https://www.geisinger.org/-/media/OneGeisinger/Files/PDFs/Provider/NaviNet/Forms/medical-benefit-outpatient-drug-authorization-form-050819.pdf?sc_lang=en&hash=6EDE27E13FCCB5731E081FC49B85359D

This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. MBODAQuestionnaireThis is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.Questionnairehttp://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire#1.0.0
... diagnosis-infoDiagnosis Information0..1group
.... diagnosis-info|diagnosis-codeDiagnosis/ICD-10 code(s)0..*open-choice
.... diagnosis-info|diagnosis-descriptionDiagnosis description0..*string
... medication-infoMedication Information0..1group
.... medication-info|nameMedication name0..1string
.... medication-info|doseDose0..1quantity
.... medication-info|routeRoute0..*open-choice
.... medication-info|frequencyFrequency0..1quantity
.... medication-info|therapy-lengExpected length of therapy0..1quantity
.... medication-info|num-visitsQuantity/number of requested visits0..1integer
.... medication-info|service-dateAnticipated/actual date of service0..1date
.... medication-info|new-medNew Medication or Continued Therapy0..1choiceOptions: 2 options
.... medication-info|date-initiallizedDate therapy initially started0..1dateEnable When: medication-info|new-med =
.... medication-info|requested-drug-codeHCPCS/CPT code/J code/NDC code of requested drug0..1string
.... medication-info|associated-procedureAssociated procedure codes requiring prior auth0..1string
... request-for-expedited-reviewRequest for Expedited Review0..1group
.... request-for-expedited-review|paraWhen a request needs to be reviewed in an expedited manner because the standard review time frame may SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION, note this below by checking URGENT in the space provided, along with the reason the request is urgent. Requests will not be processed as urgent unless a rationale for urgency is provided.0..1group
..... request-for-expedited-review|rationaleURGENT - rationale0..1string
... ordering-provider-signatureOrdering Provider Signature0..1group
.... ordering-provider-signature|author-signatureSignature:0..1attachment

doco Documentation for this format

Options Sets

Answer options for medication-info|new-med

  • http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#NewMedication ("New Medication")
  • http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy ("Continuation of therapy")